Background <p>Periorbital muscle hyperactivity is a growing concern leading to unsatisfactory eyelid appearance after blepharoplasty. The purpose of this study was to investigate the effectiveness of botulinum toxin in improving eyelid appearance after blepharoplasty with periorbital muscle hyperactivity.</p> Methods <p>Fifty-one patients received botulinum toxin injections to correct unsatisfactory eyelid appearance due to periorbital muscle hyperactivity, such as asymmetrical folds, eyebrow elevation, and undesirable fold contour. We used a strategy of overall relaxation of the periorbital muscles. The patients were divided into the eyebrow elevation group and the frowning group with the appropriate injection method. Patients were followed up at 3 months after injection to assess outcomes.</p> Results <p>Of 51 cases to correct unsatisfactory eyelid appearance after blepharoplasty, almost all could achieve satisfactory fold (94.1%). Of these, 32 patients were assigned to the eyebrow elevation group and 19 patients to the frowning group. After the physician assessed efficacy, 32 cases, 16 cases, and 3 cases were classified as excellent, good, and poor results at 3 months, respectively.</p> Conclusions <p>The unsatisfactory fold of the blepharoplasty caused by periorbital muscle hyperactivity can be corrected by botulinum toxin injections. To avoid assessing the eyelids in isolation, dynamic and comprehensive evaluations of the brow-eyelid continuum are required in clinical practice.</p> Level of Evidence IV <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a>.</p>